Healthcare Provider Details

I. General information

NPI: 1316027055
Provider Name (Legal Business Name): LETHA DENISE GIDHARRY P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10061 SWEETWATER PKWY
JACKSONVILLE FL
32256-3977
US

IV. Provider business mailing address

3001 SPRING FOREST RD
RALEIGH NC
27616-2815
US

V. Phone/Fax

Practice location:
  • Phone: 904-519-1034
  • Fax:
Mailing address:
  • Phone: 919-424-5080
  • Fax: 919-424-5085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17163
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 20354
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: